WS 445.13-2014Basic dataset of electronic medical record. Part 13: Inpatient progress note (English PDF)

Foreword

This standard was drafted in accordance with the rules given in GB/T 1.1-2009.

WS 445 "EMR basic data set" is divided into 17 parts.

--- Part 1. medical records summary;

--- Part 2. Door (urgent) medical records;

--- Part 3. door (urgent) consultation prescription;

--- Part 4. Inspection records;

--- Part 5. General treatment records;

--- Part 6. midwifery records;

--- Part 7. Nursing operation records;

--- Part 8. Nursing assessment and planning;

--- Part 9. informed information;

--- Part 10. Inpatient medical records home page;

--- Part 11. Chinese medical records Home;

--- Part 12. admission records;

--- Part 13. Inpatient course records;

--- Part 14. hospital doctor's advice;

--- Part 15. discharge summary;

--- Part 16. Referral (hospital) records;

--- Part 17. Medical institutions information.

This section is the 13th part of WS 445.

This section mainly drafted by. General Hospital of Chinese People's Liberation Army, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine (Chinese medicine hospital medical quality Monitoring Center), Shengjing Hospital Affiliated to China Medical University, Ministry of Health Statistics Information Center.

1 Scope

This part of WS 445 specifies the data set metadata attributes and data element attributes of the basic data set of in-hospital records.

This section applies to guide the acquisition of basic information of disease records, storage, sharing and information system development.

2 Normative references

The following documents for the application of this document is essential. For dated references, only the dated version applies to this article Pieces. For undated references, the latest edition (including all amendments) applies to this document.

GB/T 2261.1-2003 personal basic information classification and code - Part 1. human gender code Classification and code of TCM syndromes GB/T 15657-1995 Chinese medicine clinical diagnosis and treatment of terminology part of the law GB/T 16751.3-1997 Health Information Data Element Value Area Code Part 12. Planning and Intervention Health information data - Element code area code - Part 15. Health personnel WS 370-2012 Health Information Basic Data Set Compilation Specifications WS 445.1-2013 Electronic Medical Record Basic Data Set Part 1. Medical Record Summary ICD-9-CM-3 International Classification of Diseases, 9th Edition, Revision 3, Volume 3 ICD-10 International Classification of Diseases 10th Edition

3 Terms and definitions

The terms and definitions defined in WS 370-2012 and WS 445.1-2013 apply to this document.

4 Dataset metadata attributes

According to WS 370-2012, the dataset metadata attributes are shown in Table 1.